| Introduction |
poststroke spasticity: treating to the disability.
- Brainin, Michael. Pages: S1-S4
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| Article |
the global burden of stroke and need for a continuum of care.
- Norrving, Bo, MD, PhD, Kissela, Brett. Pages: S5-S12
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Until 4 decades ago, the rates of stroke in low- and middle-income countries were considerably lower than those in more economically robust countries. In the intervening years, however, the rates of stroke in places such as southern India and rural South Africa have approximately doubled, whereas stroke rates in more economically developed nations have decreased. What is far more striking is that rates of disability and mortality arising from stroke are at least 10 times greater in medically underserved regions of the world compared with the most developed nations. The causes of these disparities are clear: above all, there is a lack of primary care treatment to screen patients for stroke risk and to mitigate risk factors. In addition, the lack of access to common drugs and basic medical equipment, as well as the lack of poststroke follow-up programs, rehabilitation, and secondary stroke prevention, means that individuals who would, in countries with better medical care, likely recover from stroke, instead have high rates of death and disability. Several global organizations, most notably the World Health Organization, have formulated and begun to implement public health programs to address these underserved regions. Their success depends on the support and expansion of these efforts so that short-term response to stroke, long-term stroke prevention and care, and screening and treatment of poststroke disabilities can be improved in underserved regions and the human and economic burden on these populations can be minimized.(C)2013 American Academy of Neurology
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toward an epidemiology of poststroke spasticity.
- Wissel, Jorg, MD, FRCP, Manack, Aubrey, Brainin, Michael. Pages: S13-S19
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Poststroke spasticity (PSS)-related disability is emerging as a significant health issue for stroke survivors. There is a need for predictors and early identification of PSS in order to minimize complications and maladaptation from spasticity. Reviewing the literature on stroke and upper motor neuron syndrome, spasticity, contracture, and increased muscle tone measured with the Modified Ashworth Scale and the Tone Assessment Scale provided data on the dynamic time course of PSS. Prevalence estimates of PSS were highly variable, ranging from 4% to 42.6%, with the prevalence of disabling spasticity ranging from 2% to 13%. Data on phases of the PSS continuum revealed evidence of PSS in 4% to 27% of those in the early time course (1-4 weeks poststroke), 19% to 26.7% of those in the postacute phase (1-3 months poststroke), and 17% to 42.6% of those in the chronic phase (>3 months poststroke). Data also identified key risk factors associated with the development of spasticity, including lower Barthel Index scores, severe degree of paresis, stroke-related pain, and sensory deficits. Although such indices could be regarded as predictors of PSS and thus enable early identification and treatment, the different measures of PSS used in those studies limit the strength of the findings. To optimize evaluation in the different phases of care, the best possible assessment of PSS would make use of a combination of indicators for clinical impairment, motor performance, activity level, quality of life, and patient-reported outcome measures. Applying these recommended measures, as well as increasing our knowledge of the physiologic predictors of PSS, will enable us to perform clinical and epidemiologic studies that will facilitate identification and early, multimodal treatment.(C)2013 American Academy of Neurology
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pathophysiology of spasticity in stroke.
- Burke, David, MD, DSc, Wissel, Jorg, MD, FRCP, Donnan, Geoffrey. Pages: S20-S26
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Spasticity is defined clinically by increased muscle tone and tendon jerk hyperreflexia in patients who are at rest. However, the excitability of spinal circuits changes during movement, and this definition provides no insight into the extent to which spasticity and associated motor disturbances cause disability. Only a few spinal circuits have been shown to underlie the abnormalities of patients at rest. Movement can be restrained by pathologically enhanced muscle tone, and there is defective control of the feedback to active motoneurons through virtually all spinal reflex pathways. Spasticity does not necessarily require treatment: in fact, some patients rely on the increased muscle tone to help support otherwise weak muscle contractions for stance and locomotion. In addition, much of the increase in muscle tone arises from changes in muscle and motor units, independent of reflex mechanisms. Managing a patient with impairment after a stroke requires therapy tailored to that particular patient because the mechanisms contributing to the disability experienced by one patient may differ from those affecting another.(C)2013 American Academy of Neurology
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the interaction between neuropsychological and motor deficits in patients after stroke.
- Chen, Christopher, MD, FRCP, Leys, Didier, MD, PhD, Esquenazi, Alberto. Pages: S27-S34
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Stroke survivors typically experience varying degrees of motor and neuropsychological deficits. Although these deficits are frequently treated as separate entities in the cognitive and physical rehabilitation settings, there is considerable interaction between them. Cognitive-motor interference, for example, refers to the simultaneous performance of cognitive and motor functions that results in diminished execution of one or both of the tasks. Studies have demonstrated that when performing dual tasks, poststroke patients will typically favor the cognitive function over the motor task. Furthermore, only certain cognitive functions will interfere with motor abilities, while the intensity of the motor task may magnify the detriment in dual-task performance. Moreover, mood disorders, particularly depression, have also been shown to interact substantially with physical functioning. Consequently, poststroke patients with depression experience greater reductions in their activities of daily living and worse rates of recovery. Recent neuroimaging studies suggest an association between white matter hyperintensities and both motor and neuropsychological poststroke deficits. The relationship between spasticity and cognition deficits needs to be further explored with regard to the deleterious consequences of poststroke spasticity on quality of life and overall motor function. These insights, among others, contribute to a growing, if embryonic, body of knowledge about poststroke motor/cognitive interaction that will ultimately inform developments in treatment and rehabilitation.(C)2013 American Academy of Neurology
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assessing and treating functional impairment in poststroke spasticity.
- Sunnerhagen, Katharina, MD, PhD, Olver, John, MBBS, MD, Francisco, Gerard. Pages: S35-S44
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Poststroke spasticity (PSS) is associated with significant consequences for a patient's functional status and quality of life. Nonetheless, no uniform definition of spasticity exists that can be utilized across clinical research settings, and difficulties in validating proper assessment tools-both clinical and nonclinical-complicate the ability to evaluate and appropriately treat spasticity. Consequently, the current state of defining, assessing, and treating spasticity requires improved consistency and ongoing validation as clinical research efforts advance. When selecting clinical measures for PSS assessment (e.g., the Modified Ashworth, Tone Assessment, Tardieu, Modified Rankin, and Disability Assessment scales, and the Barthel Index), it is critical to understand the levels of impairment or functional limitation each tool assesses as well as their benefits and limitations. The use of quantitative methods-such as electrophysiologic, biomechanical, and imaging techniques-adjunctive to traditional clinical measures also allows for sensitivity in quantifying the abnormal muscle activity associated with spasticity. In addition to accurate evaluation and assessment of PSS, realistic treatment goal setting for patients as well as family members and caregivers is critical, because it promotes motivation and cooperation as well as proper management of expectations and can favorably affect recovery. Goal attainment scaling has been shown to help organize, focus, and clarify the aims of treatment, thereby enhancing the PSS rehabilitative process. Furthermore, integration of therapeutic modalities and treatment strategies, including both nonpharmacologic intervention and pharmacotherapy, is also important for improved outcomes.(C)2013 American Academy of Neurology
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poststroke spasticity: sequelae and burden on stroke survivors and caregivers.
- Zorowitz, Richard, Gillard, Patrick, PharmD, MS, Brainin, Michael. Pages: S45-S52
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Among the estimated 20% to 40% of stroke survivors who develop spasticity, the burden of this condition on patients, caregivers, and society is substantial. Stroke survivors with spasticity may experience reductions in their ability to perform activities of daily living and in their health-related quality of life. The occurrence of spasticity in stroke survivors may also result in an increased burden on their caregivers, who exhibit poorer physical and emotional health as compared with the general population. The responsibilities that caregivers have to the stroke survivor-in terms of providing medical care, protecting from falls, and assisting with feeding and hygiene, among other tasks of daily living-must be balanced with their responsibilities to other family members and to themselves. Caregivers of stroke survivors often report a feeling of confinement with little opportunity for relief, and although social support can be helpful, it is frequently limited in its availability. In terms of the socioeconomic burden of spasticity after stroke, recent data point to a 4-fold increase in health care costs associated with stroke survivors with spasticity compared with stroke survivors without spasticity. Thus, it is important to reduce the burden of spasticity after stroke. Consequently, effective spasticity treatment that reduces spasticity and the level of disability experienced by stroke survivors will likely increase their functioning and their health-related quality of life and will also result in a diminished burden on their caregivers.(C)2013 American Academy of Neurology
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